Hi, I'm Chris Fulmer. I'm one of the faculty members for the Stanford O'Connor Sports Medicine Fellowship. In this case, we're presented with a patient who has suffered blunt force trauma to the face. I'll focus on the assessment of any injury to the eye itself or to the bony elements of the orbit. The first thing you want to do if you have any suspicion to injury to the eye is test the patient's visual acuity. After I've done that, I'll assess the shape, size, and reactivity of his pupil. I'm not going to demonstrate that today, but basically you would just use your pen light or other light source to look at this. You want to pay special attention to the appearance of the globe itself, looking for signs of globe rupture, which would be a change in shape of the pupil itself, a hyphema, or any changes in the contour of the injured eye versus the other things such as n-ophthalmos or exophthalmos. Once you've done a visual inspection, you want to do your palpatory exam. I'll start with palpating the inferior border of the orbit, palpating along here, and extending all the way laterally to include palpation of the zygomatic arch. I'll also assess for integrity of sensation of the inferior orbital branch of the maxillary nerve, testing sensation on one cheek versus the other, looking for numbness, paresthesias, dysesthesias, also palpating directly over the inferior orbital foramen here. Once I've palpated there, I'll also palpate the accessible elements of the medial orbital wall, palpating just along the upper part of the nose and into the actual structures of the medial part of the orbit. Once I've done my palpatory exam, the next component to include is testing of the extraocular muscles. So focusing on the cardinal movements of the eye, so follow my finger just with your eyeballs. I'm testing lateral movements of the eye, superior and inferior movements of the eye. While I'm testing the integrity of the extraocular muscles, I'm also going to inquire of the patient whether they note any diplopia or changes in their vision as they're moving their eyes. The most important thing to rule out with this part of the exam is entrapment of either the inferior rectus or the inferior oblique muscles, which considering the inferior wall of the orbit is most commonly fractured, those two muscles can be entrapped and your typical sign of that would be pain or diplopia with testing those muscles, so with either inferior gaze or superior gaze.

2nd Edition, CASE 09

2nd Edition

Eye

eye injuries

orbital trauma

visual acuity

muscle entrapment

globe rupture